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Last week I posted an article about Blue Cross Blue Shield and its agreement to pay families of autistic children a total of $1 million for behavioral therapy coverage. Although this settlement is a step in the right direction, health plans have a long way to go before children with special needs receive fair treatment.

Developmental problems are pervasive in their nature. They affect nearly every aspect of a child’s life. Some disorders, such as birth-trauma induced cerebral palsy, impact both the mental and the physical development of the child. As a result, these children often require specialized equipment, supplies, services, or devices able-bodied children do not need.

Unfortunately, health plans and insurance companies characterize such special requirements as not "medically necessary" – almost always at the plan administrator’s sole discretion – and deny these benefits. As a result, many families are forced to pay expenses out of pocket or to make the unsettling choice of forcing their child to do without the needed benefit. Compounding the insult is the fact that the law makes it exceedingly difficult to reverse the decision of the plan administrator.

One glaring example of the anti-consumer state of the law is the Employee Retirement Income Security Act (ERISA). Originally designed as a measure to protect workers and ensure they would receive the promised benefits of their employment, a series of court decisions over the past two decades gave plan administrators tremendous authority to deny claims. Only very recently have some Courts begun ruling in favor of individuals instead of corporations.

The time period in which to challenge an adverse decision is usually very limited. If your health plan has denied a claim you believe you are entitled to, contact us to see if we can help.


  1. Gravatar for Gabrielle D'Alemberte
    Gabrielle D'Alemberte

    Nice post. Please keep this dialogue going.

    Consumers should be further informed and educated. Instead of focusing on what SOUNDS like a lot of money in cases involving severely injured children, people should know the REAL impact of what happens when a settlement is insufficient, when insurance fails to pay (obviously only in the case where there has been actual wrongdoing), and WHY the verdicts/settlements are "large". The exorbitant costs of health care make the cost of a special needs life so expensive that the only hope for a injured child to have adequate support during his/her lifetime is if litigation against a wrong-doer is able to compensate for their future.

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